We recently caught up with Robert Rowley, MD, Co-Founder and Chief Medical Officer of Flow Health, The Operating System for Value-Based CareSM, to discuss practices outsourcing chronic care management services as well as the services that Flow Health offers to physician practices. Some of our readers may know Bob as the former Chief Medical Officer of Practice Fusion, the cloud-based electronic health record company.

Mary Pat: What is the Medicare Chronic Care Management (CCM) program?

Bob: In 2015, Medicare began a new program called Chronic Care Management (CCM) and established a new billing code for it – 99490. This is an initial step away from in-office, traditional care, and starts to promote (i.e., pay for) regular contact with patients in between office visits. A Medicare patient must first enroll in the service, since there is a charge for it – payable by Medicare just like any other service. Then, once a month, a CCM nurse will reach out to the patient, usually by phone, and review the patient’s treatment plan with them. Once 20 minutes each month has been spent addressing the patient’s case, a bill is generated. This service is unlike Case Management, or Home Health, which are intended for the 5% or so of Medicare enrollees who are very ill and need intensive support. Instead, the CCM service is intended for all Medicare enrollees with 2 or more chronic conditions – estimated to be about 80% of all Medicare members.

Mary Pat: Why have few physicians implemented CCM in their practices?

Bob: After a year of implementation, Medicare is discouraged at the low uptake of this new code by clinicians. According to CMS, CCM services have only been billed for 100,000 patients, out of 35 million enrollees – 0.029% of the potential. Why is that? There are a number of barriers:

The code is new, and physicians are just starting to become aware of it.

The service is burdensome, especially for smaller practices. It may involve hiring extra staff to do the CCM nurse calling. It involves extra billing – an extra bill for every enrolled Medicare member every month. The reimbursement from Medicare (about $40-44 per patient each month) may not cover the overhead of CCM nursing staff and billing.

Medicare wants a connected health platform, so that everyone taking care of the patient can see what is going on, and a consolidated care plan can be developed, understood by all. This is hard to achieve in a disaggregated, siloed environment

Mary Pat: What are the benefits of CCM to a small practice?

Bob: Medicare’s CCM service is like a non-physician health coach that reaches out from the practice to the patient and makes sure the care plan is understood, and “checks up” on the patient. If a patient does not want the service, after initially signing up for it, he or she can disenroll from the service at any time. In our experience, very few patients disenroll; most appreciate the extra outreach. The practice gets improved patient engagement and satisfaction, with fewer patients “falling through the cracks.”

Mary Pat: Tell me about Flow Health.

Bob: Flow Health is a universal patient-centered data platform that can draw from all separate sources of information and put it all in one place, unifying the data into a standard form. It can organize a patient’s data, and make it immediately and universally useful. Flow Health also has a suite of apps that sit on this data platform, and allow direct access to this data – a patient-facing app (called Guide), a provider-facing app, and a point-of-care app (Patient Check-In). Flow Health interfaces in the background with connected EHRs in physician offices, so that the data appears “native” to each EHR, and is updated whenever an event occurs in any connected care team member’s systems.

Mary Pat: How does Flow Health address CCM for practices?

Bob: Flow Health offers a full-service outsourced CCM service to medical practices. Flow Health hires the CCM nurses, who present themselves to patients as members of the medical practice, and have all the collected information about the patient and the care plans at their fingertips. Then, when the interaction has reached 20 minutes cumulatively over the month, a bill is sent on behalf of the practice for the CCM service. This allows smaller practices to participate in CCM without having to encumber the overhead required (staff, billing, connected platform).

Flow Health charges a portion of the bill as a fee to cover the cost of administering the service (CCM nurses, billing and platform), and the practice enjoys new revenue from Medicare without the down-side of out-of-pocket expenses to set up and run the new service.

Mary Pat: How much of the monthly Medicare reimbursement does the practice get?

The practice nets about $10-$15 per patient per month or approximately 25% of the Medicare allowable.

Mary Pat: What is the process for outsourcing CCM to FlowHealth?

A practice interested in participating in CCM and wanting the Flow Health outsourced solution simply contacts Flow Health, and an implementation process begins. Integration with the practice’s EHR is set up, which will vary depending on the EHR the practice uses. The Check-In app, deployed on iPads that Flow Health provides for office-lobby use, captures patient consent and on-boards patients into the system so that they can effectively use the patient-facing Guide app subsequently. The mechanism for billing Medicare for the service is set up.

Mary Pat: How does the Check-In app work?

Bob: Using the Check-In app facilitates enrollment in CCM for candidate patients. The authorization forms are embedded in the app, and appear when the patient is a Medicare enrollee with 2 or more chronic conditions. The Check-In app also collects numerous other data (pre-populated as much as possible), including the history of present illness, past medical history, and all the other things generally included on a paper check-in clipboard. It can be used for all of the practice’s patients, not just CCM patients, since its information is linked with the practice’s EHR

Mary Pat: Who supervises the CCM nurses?

Flow Health sets up teams of CCM nurses comprised of a mixture of Medical Assistants trained in CCM and supervising RNs. The notes from the CCM encounters are posted on the Flow Health platform, which the physician office staff can see using the provider-facing app. If there are suggestions and improvements that the clinician feels are important, these can be communicated using the provider app, or by phone. Every attempt is made to assign the same CCM nurse to the same patients, so that longitudinal relationships and trust can be built